November 5 Update (Updated graph pasted by Lisa Quinones - information below the graph is from Chris Farnitano):
The number of influenza-like illnesses has markedly increased over the past few weeks at this start of flu season.
Updates of this graph may be seen at: http://www.cdc.gov/flu/weekly/
Graph of U.S. patient visits reported for Influenza-like Illness (ILI) for week ending October 24, 2009.
There have also been several reports nationwide of outbreaks at college campuses. Anecdotally several CCHS clinicians I spoke with this week have seen an increase in influenza like illnesses. So it may be that after dying down in midsummer H1N1 is roaring back quite early this fall, 2 months before we expect to receive any H1N1 vaccine. So we could be in for a long winter.
Just to review a few flu issues:
1. The rapid flu test is no better than flipping a coin for detecting H1N1. Don't use it (possibly some role for ruling in low suspicion hospitalized cases on the weekends when the PCR test result will not be run until Monday)
2. The PCR nasal swab will only be run on inpatients. Diagnose and treat outpatients clinically.
3. Emphasis on treatment should be on hospitalized patients regardless of how long they have been sick and outpatients at high risk if treatments started in first 48 hours.
4. High risk groups are:
Children younger than 5 years old. The risk for severe complications from seasonal influenza is highest among children younger than 2 years old.
Immunosuppression, including that caused by medications or by HIV;
Pregnant women;
Persons younger than 19 years of age who are receiving long-term aspirin therapy;
Residents of nursing homes and other chronic-care facilities.
Oseltamivir use for children <1 year old was recently approved by the U.S. Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA), and dosing for these children is age-based Table 2. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.||~ Age ||~ Recommended treatment dose for 5 days ||
<3 months
12 mg twice daily
3-5 months
20 mg twice daily
6-11 months
25 mg twice daily
5. For patients not in high risk groups the benefit of antivirals is modest (about 1/2 day quicker resolution of sx) and antivirals should generally not be offered, although it is at the clinician's discretion. If we develop an antiviral shortage we should definitely limit antivirals to high risk patients only.
6. When vaccine is first available, ACIP recommends that programs and providers administer vaccine to persons in the following five target groups (order of target groups does not indicate priority):
pregnant women,
persons who live with or provide care for infants aged <6 months (e.g., parents, siblings, and daycare providers),
health-care and emergency medical services personnel,§
persons aged 6 months--24 years, and
persons aged 25--64 years who have medical conditions that put them at higher risk for influenza-related complications.¶
Note this intentionally does not include anyone over age 65 as they are felt to have some immunity to H1N1 due to previous exposures with similar viruses. They may be allowed to get vaccine late in the season if supply warrants after the high risk group's needs have been met.
7. It is still not clear whether 1 or 2 doses of vaccine will be needed. Stay tuned.
Chris Farnitano, MD
Family Medicine Department Chair
Contra Costa Health Services
Flu Vaccines
Candidates for the live nasal vaccine - Seasonal flu vaccine (Flumist).
-age 2-49
-do not have asthma or other chronic pulmonary condition, heart disease (hypertension is OK), renal, hepatic, neuro, hematologic or metabolic disease (including diabetes), or other immunosuppresive condition
-children 2-8 need a second dose >4 weeks apart if this is first vaccination year.
(Per email from Chris Farnitano 10/09)
Who to Treat
You should treat a patient with Influenza Like illness empirically if they are:
· Within 48 hours of illness onset
· Pregnant or up to 2 weeks post partum
· Age 65 or older
· Person of any age with certain chronic medical or immunosuppressive conditions
· Persons younger than 19 years who are receiving long term aspirin therapy
· Children under 2 ( may consider up to 4 years, while risk of severe illness is great for children under 4, risk is greatest for children under 2)
Table of Contents
The number of influenza-like illnesses has markedly increased over the past few weeks at this start of flu season.
Updates of this graph may be seen at:
http://www.cdc.gov/flu/weekly/
There have also been several reports nationwide of outbreaks at college campuses. Anecdotally several CCHS clinicians I spoke with this week have seen an increase in influenza like illnesses. So it may be that after dying down in midsummer H1N1 is roaring back quite early this fall, 2 months before we expect to receive any H1N1 vaccine. So we could be in for a long winter.
Just to review a few flu issues:
1. The rapid flu test is no better than flipping a coin for detecting H1N1. Don't use it (possibly some role for ruling in low suspicion hospitalized cases on the weekends when the PCR test result will not be run until Monday)
2. The PCR nasal swab will only be run on inpatients. Diagnose and treat outpatients clinically.
3. Emphasis on treatment should be on hospitalized patients regardless of how long they have been sick and outpatients at high risk if treatments started in first 48 hours.
4. High risk groups are:
- Children younger than 5 years old. The risk for severe complications from seasonal influenza is highest among children younger than 2 years old.
- Adults 65 years of age and older.
- Persons with the following conditions:
- Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus);
- Immunosuppression, including that caused by medications or by HIV;
- Pregnant women;
- Persons younger than 19 years of age who are receiving long-term aspirin therapy;
- Residents of nursing homes and other chronic-care facilities.
Oseltamivir use for children <1 year old was recently approved by the U.S. Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA), and dosing for these children is age-basedTable 2. Dosing recommendations for antiviral treatment of children younger than 1 year using oseltamivir.||~ Age ||~ Recommended treatment dose for 5 days ||
5. For patients not in high risk groups the benefit of antivirals is modest (about 1/2 day quicker resolution of sx) and antivirals should generally not be offered, although it is at the clinician's discretion. If we develop an antiviral shortage we should definitely limit antivirals to high risk patients only.
6. When vaccine is first available, ACIP recommends that programs and providers administer vaccine to persons in the following five target groups (order of target groups does not indicate priority):
- pregnant women,
- persons who live with or provide care for infants aged <6 months (e.g., parents, siblings, and daycare providers),
- health-care and emergency medical services personnel,§
- persons aged 6 months--24 years, and
- persons aged 25--64 years who have medical conditions that put them at higher risk for influenza-related complications.¶
Note this intentionally does not include anyone over age 65 as they are felt to have some immunity to H1N1 due to previous exposures with similar viruses. They may be allowed to get vaccine late in the season if supply warrants after the high risk group's needs have been met.7. It is still not clear whether 1 or 2 doses of vaccine will be needed. Stay tuned.
Chris Farnitano, MD
Family Medicine Department Chair
Contra Costa Health Services
Flu Vaccines
Candidates for the live nasal vaccine - Seasonal flu vaccine (Flumist).
-age 2-49
-do not have asthma or other chronic pulmonary condition, heart disease (hypertension is OK), renal, hepatic, neuro, hematologic or metabolic disease (including diabetes), or other immunosuppresive condition
-children 2-8 need a second dose >4 weeks apart if this is first vaccination year.
(Per email from Chris Farnitano 10/09)
Who to Treat
You should treat a patient with Influenza Like illness empirically if they are:· Within 48 hours of illness onset
· Pregnant or up to 2 weeks post partum
· Age 65 or older
· Person of any age with certain chronic medical or immunosuppressive conditions
· Persons younger than 19 years who are receiving long term aspirin therapy
· Children under 2 ( may consider up to 4 years, while risk of severe illness is great for children under 4, risk is greatest for children under 2)
(Per email from Chris Farnitano 10/09)